Journal Article > Study

Electronic health records (EHRs) hold great promise for improving patient safety, but remain underutilized, especially in ambulatory care settings. Failure to appropriately follow up on abnormal test results is a common ambulatory care safety problem, and has been implicated in malpractice lawsuits arising from missed or delayed diagnoses. In this study conducted at eight family medicine clinics, those with an EHR documented clinician and patient notification of abnormal test results and clear follow-up plans more often than those with paper charts. However, even in clinics using EHRs, more than one-third of abnormal results had no follow-up plan documented. This finding corroborates prior research that clinician notification alone does not ensure timely and complete follow-up of test results.

Journal Article > Study

Malpractice risk in outpatient primary care is increasingly under scrutiny. This study screened malpractice claims from two Massachusetts insurers and found that those from outpatient primary care settings were more likely to be settled or found in favor of the plaintiff compared with those from other practice settings. Similar to previous research, claims related to missed and delayed diagnoses were most frequent, and the most common disease involved was cancer, followed by cardiovascular disease. The accompanying editorial argues that primary care settings will become increasingly important for malpractice claims with the advent of patient-centered medical homes and accountable care organizations, which shift a larger proportion of medical care to the outpatient primary care setting. The authors note a high prevalence of failure-to-diagnose claims and recommend further emphasis on diagnostic safety. A missed diagnosis of myocardial infarction was discussed in an AHRQ WebM&M commentary.

Journal Article > Study

The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.

Journal Article > Review

This systematic review of 34 studies of malpractice claims in primary care from five countries identified diagnostic errors and medication errors as the most common types of preventable adverse events in ambulatory medicine. Missed and delayed diagnoses—particularly of cancer and myocardial infarction—were also found to be a main source of malpractice lawsuits in another recent study, which was not included in this analysis. Although malpractice claims are an imperfect data source, this study provides important information to help focus efforts to improve patient safety in ambulatory care.

Journal Article > Study

This retrospective examination of closed malpractice claims against dermatologists identified procedural errors and missed diagnoses as the most frequent types of claims. As with malpractice claims across other specialties, most were dismissed or withdrawn.

Journal Article > Study

Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.